Food Safety Incident Report
Incident Details
Date of Incident
Time of Incident
Location (Site, Address, Department, etc.)
Food Involved
Description of Incident
People Involved
Name(s) of Individual(s) Involved
Contact Information
Witnesses (if any)
Actions Taken
Immediate Actions Taken
Was Medical Assistance Required?
Yes
No
Other Agencies Notified (if any)
Follow-up & Preventive Actions
Follow-up Actions Planned or Recommended
Person Responsible for Follow-up
Reporting
Reported By
Date of Report
Signature